Endovascular treatment of a patient with multifocal occlusal-stenotic lesion of the head main arteries using a modified anchor stenting technique and confirming the efficacy and adequacy of treatment by controlling changes in cerebral hemoperfusion

  • Yu.V. Cherednychenko PI «I.I. Mechnikov Dnipropetrovsk Regional Clinical Hospital». SI «Dnipropetrovsk Medical Academy of the Ministry of Health of Ukraine» https://orcid.org/0000-0002-2683-8608
  • A.Yu. Miroshnychenko PI «I.I. Mechnikov Dnipropetrovsk Regional Clinical Hospital»
  • L.A. Dzyak SI «Dnipropetrovsk Medical Academy of the Ministry of Health of Ukraine»
  • M.O. Zorin SI «Dnipropetrovsk Medical Academy of the Ministry of Health of Ukraine»
  • N.O. Cherednychenko SI «Dnipropetrovsk Medical Academy of the Ministry of Health of Ukraine»
Keywords: occlusive and stenotic lesion; main arteries of the head; endovascular treatment; stenting; anchor technique; computed tomographic perfusiography of the brain.

Abstract

A case of treating of 59 years old patient with a multifocal occlusive and stenotic lesion of the main arteries of the head is described. Patients has occlusions of both internal carotid arteries, left external carotid artery, right vertebral artery, severe stenosis in the initial segment of the left subclavian artery and severe stenosis in the ostium of the left vertebral artery, with cognitive impairment and coordination disorders.
A single-session stenting of the stenosis in the ostium of left vertebral artery with balloon-expan-
dable elution-stent with usage of the modified Szabo anchor technique and stenting of the stenosis in the initial segment of the subclavian artery with a balloon-expandable peripheral stent was performed. Stenoses are eliminated, all cerebral arteries of the vertebrobasilar basin and both carotid basins are supplied by the left vertebral artery.
After 50 days, the patient’s neurological status was assessed and a computed tomographic perfusiography of the brain was performed. The cognitive status improved significantly (initially – 23 points on the MoCA scale, after the operation – 27 points), coordination disorders regressed. According to computed tomographic brain perfusion, there are increase in CBF (cerebral blood flow) above normal in all areas except for the area of ​​stroke; an increase in CBV (cerebral blood volume) above normal, which is a reflection of arterioles vasodilation; increase in MTT (mean transit time) in all zones, which is a sign of collateral blood flow. Based on these data, it was concluded that further revascularization operations on the occluded cerebral arterial basins can lead to the hyperperfusion syndrome clinical manifestation. The performed endovascular stage of treatment was effective and sufficient to significantly improve the patient’s neurological and cognitive status and prevent the development of recurrent ischemic stroke.

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References

Brott TG, Hobson RW II, Howard G, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010 Jul 1;363(1):11-23. doi: 10.1056/NEJMoa0912321.

Stabile E, Salemme L, Sorropago G, et al. Proximal endovascular occlusion for carotid artery stenting: Results from a prospective registry of 1,300 patients. J Am Coll Cardiol. 2010 Apr 20;55(16):1661-7. doi: 10.1016/j.jacc.2009.11.079.

Howard VJ, Lutsep HL, Mackey A, et al. Influence of sex on outcomes of stenting versus endarterectomy: a subgroup analysis of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Lancet Neurol. 2011 Jun;10(6):530-7. doi: 10.1016/S1474-4422(11)70080-1.

Massop D, Dave R, Metzger C, et al. Stenting and angioplasty with protection in patients at high-risk for endarterectomy: SAPPHIRE Worldwide Registry first 2,001 patients. Catheter Cardiovasc Interv 2009 Feb 1;73(2):129-36. doi: 10.1002/ccd.21844.

Ederle J, Bonati LH, Dobson J, et al. Endovascular treatment with angioplasty or stenting versus endarterectomy in patients with carotid artery stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): long-term follow-up of a randomised trial. Lancet Neurol 2009 Oct;8(10):898-907. doi: 10.1016/S1474-4422(09)70228-5.

Mehdorn HM. Cerebral revascularization by EC-IC bypass present status. Acta Neurochir Suppl. 2008;103:73-7. Review. PubMed PMID: 18496948.

Fiorella D, Heiserman J, Prenger E, Partovi S. Assessment of the reproducibility of postprocessing dynamic CT perfusion data. AJNR. 2004;25(1):97-107.

Garrett MC, Komotar RJ, Starke RM et al. Radiographic and clinical predictors of hemodynamic insufficiency in patients with athero-occlusive disease. J Stroke Cerebrovasc Dis. 2008 Nov-Dec;17(6):340-3. doi: 10.1016/j.jstrokecerebrovasdis.2008.04.005. Review. PubMed PMID: 18984424.

Gibbs JM, Wise R, Thomas D, et al. Cerebral hemodynamic changes after extracranial-intracranial bypass surgery. JNNP. 1987;50(2):140-50. doi:10.1136/jnnp.50.2.140

Gibbs JM, Leenders KL, Wise R, Jones T. Evaluation of cerebral perfusion reserve in patients with carotid-artery occlusion. Lancet. 1984;1:182-6.

Ko NU, Achrol A, Chopra M, et al. Cerebral blood flow changes after endovascular treatment of cerebrovascular stenosis. AJNR. 2005;26(3):538-42.

Moftakhar R, Turk AS, Niemann DB et al. Effects of carotid or vertebrobasilar stent placement on cerebral perfusion and cognition. AJNR. 2005;26(7):1772-80. PubMed PMID: 16091529.

Roberts HC. Dynamic CT perfusion to assess the effect of carotid revascularization in chronic cerebral ischemia. AJNR. 2000;21(2):421-5.

Szabo S, Abramowits B, Vaitkuts PT. New technique for aorto-ostial stent placement. Am J Cardiol. 2005;96:212. doi: 10.1016/j.amjcard.2005.09.057.

Kern M, Ouellette D, Frianeza T. A new technique to anchor stents for exact placement in ostial stenoses: the stent tail wire or Szabo technique. Catheter Cardiovasc Interv. 2006;68:901-6. doi: 10.1002/ccd.20613.

Feng Tang, Qian Wang, Chang Hu, Pei Li, Lei Li. Use of the Szabo technique to guide accurate stent placement at the vertebral artery ostium. J Endovasc Therapy. 2013;20 (4):554-60. doi: 10.1583/13-4298.1

Cherednichenko Yu.V. Opyit ispolzovaniya yakornoy metodiki stentirovaniya ustevyih stenozov magistralnyih arteriy golovyi (in Russian). Endovaskulyarna neyrorentgenohirurgiya (In Ukrainian). 2017;2:30-40.

Published
2019-06-13
How to Cite
Cherednychenko, Y., Miroshnychenko, A., Dzyak, L., Zorin, M., & Cherednychenko, N. (2019). Endovascular treatment of a patient with multifocal occlusal-stenotic lesion of the head main arteries using a modified anchor stenting technique and confirming the efficacy and adequacy of treatment by controlling changes in cerebral hemoperfusion. Ukrainian Interventional Neuroradiology and Surgery, 27(1), 67-75. https://doi.org/10.26683/2304-9359-2019-1(27)-67-75